Change Of Address And Contact Information Form For General Vendor Waiting List Applicants - Nyc Department Of Consumer Affairs
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1DCA LICENSING CENTER
NYC SMALL BUSINESS
42 Broadway, Lobby
SUPPORT CENTER
New York, NY 10004
90-27 Sutphin Blvd, 4th Floor
Monday-Friday: 9:00 a.m.-5:00 p.m.
Jamaica, NY 11435
Wednesday: 8:30 a.m.-5:00 p.m.
Monday-Friday: 9:00 a.m.-5:00 p.m.
nyc.gov/dca
DCA Receipt Date Stamp
Accepted by: __________
Change of Address and Contact Information Form
For General Vendor Waiting List Applicants
You must notify the Department of Consumer Affairs (DCA) in writing of any change in contact address after you
submit your General Vendor Waiting List Application. Use this form to update the address where DCA should mail
notices about the General Vendor license. You can also use this form to update your phone number(s) or email.
NAME
Last Name
Suffix
First Name
Middle Name
(e.g., Jr., Sr., Esq.)
(optional)
(optional)
DCA General Vendor Waiting List Number:
Contact Address
I would like to change my:
Phone
Email
OLD
NEW
Contact Address:
Contact Address:
(Include Building Number, Street Name, Apartment/Suite/Other;
(Include Building Number, Street Name, Apartment/Suite/Other;
City, State, ZIP Code)
City, State, ZIP Code)
Phone 1
:
Phone 1
:
(Primary)
(Primary)
Phone 2
:
Phone 2
:
(Alternate)
(Alternate)
Email:
Email:
A DCA representative will date stamp this form and return a copy to you.
I understand that falsification of any statement made herein is an offense punishable by a fine or imprisonment or
both.
_____________________________________________
_________________________________________
Signature
Print Name
_____________________________________________
Date
Updated 10/18/2016
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